Nutrition needs and best practices for formerly trafficked female children and adolescents

By Erin Lisemby

Erin Lisemby is a registered dietitian/nutritionist currently working with the US Special Supplemental Nutrition Program for Women, Infants and Children (WIC) mobile outreach programme. She has volunteered as a consultant for an anti human-trafficking organisation in Cambodia.

The United Nations defines human trafficking as “the recruitment, transportation, transfer, harbouring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose including forced labour or sexual exploitation.” (UN, 2015). In 2009, the UN published a global report that stated sexual exploitation makes up 79% of human trafficking and the majority of victims are women and girls (UN ODC, 2009).

A recent technical literature review (Lisemby, 2015) highlights a gap in research regarding the health needs of formerly trafficked female children and adolescents, with a specific focus on the Southeast Asian population. Although evidence is limited, what exists indicates common conditions of trafficking to include physical, sexual and psychological abuse, as well as neglect and deprivation (Oram et al, 2102. These can result in multiple health consequences, including malnutrition. The most commonly reported post-trafficking physical health symptoms are fatigue, headaches, sexual and reproductive health problems, back pain, significant weight loss, dizziness, memory loss, abdominal pain and dental problems.

For formerly trafficked girls in Southeast Asia, it is important to recognise their nutrition status prior to being trafficked. According to WHO, 70% of the world’s malnourished children are in Asia; anaemia, vitamin A deficiency and iodine deficiency are significant problems in this region (WHO, 2015). The severity of malnutrition in formerly trafficked females also depends on the brutality of treatment and the duration of time trafficked. There is a lack of substantial research on how physical health needs vary in relation to demographics or the characteristics of trafficking experiences; individual-level assessment and care is needed.

Nutrition needs for children and adolescents

Specific nutrient recommendations are not available for the formerly trafficked child and adolescent population, but population-based nutrition needs for this demographic can be applied. During adolescence, nutrient needs are higher than at any other time in life and full growth potential can only be reached through optimum nutrition. As a female goes through puberty, her weight and height increases, skeletal growth is completed, bone mass increases and the body begins to change in composition. Protein needs are highest between the ages of 11-14 years due to growth and increase of muscle mass. Calcium needs are greater during childhood and adolescence because of the large increase in skeletal growth. Iron needs for females increase with the start of menstruation because of rapid growth and the expansion of blood volume and muscle mass. Poor iron status during adolescence is linked to poor cognitive development into adulthood, so this nutrient needs particular attention in the formerly trafficked population. Folic acid (folate) needs are higher during adolescence because it is necessary for protein synthesis, which is increased during times of growth.

Malnutrition can be identified during a physical exam of a formerly trafficked child or adolescent and treated in accordance with international guidelines, including micronutrient supplementation where indicated. Wounds and physical injuries will increase nutrient requirements during recovery. Consideration of longer-term nutrition that centres on a nutritionally balanced and adequate diet is also needed.

Mental health

Significant mental health problems found in this population include depression, post-traumatic stress disorder (PTSD), other anxiety disorders, suicidal thoughts and disabling physical pain or dysfunction. For children, mental and emotional health is the greatest concern; prolonged physical, mental and emotional stress can cause cognitive and emotional developmental delays and possible developmental regression. When a child is undernourished, delays and regression can be more severe. Due to the prevalence of anxiety and depression in formerly trafficked children and adolescents, there is also a risk of short and long-term mood disorders, characterised by depression, anxiety, agitation, irritability, phobias, sleep and appetite disturbances, and physical signs such as fatigue, headaches and abdominal pain. Adolescent females with depressive symptoms have a higher chance of developing eating and/or substance-abuse disorders.

HIV

In 2009, the UN Development Project found no cases of HIV among formerly trafficked females in Cambodia. However, they estimated that around 75,000 people in Cambodia and 610,000 in Thailand were living with HIV in 2007 (Silverman et al, 2009). There is very little evidence to link HIV prevalence and human trafficking, but due to the nature of trafficking and the high rates of HIV in Southeast Asian countries, it is clear this population is at risk. Females who are trafficked are at a higher risk of contracting HIV due to their inability to refuse unprotected sex or negotiate condom use. The immature reproductive tracts of younger women can also facilitate HIV transmission. Although not every formerly trafficked child and adolescent may present with HIV, there is risk of transmission during trafficking experiences. Understanding the specific nutrition needs of individuals with HIV will increase the quality of care given during post-trafficking rehabilitation and recovery.

Pregnancy

In 2013, UNICEF reported that 23% of adolescent girls in the developing world give birth before age 18. In Asia, these rates are up to 40% and appear to be rising in some areas (Bhabha , 2013). Girls in trafficking are at an even higher risk of unwanted pregnancy. Giving birth as an adolescent female poses major risks to the female and the child. Pregnancy during these years puts a female at risk for pregnancy complications, which increase teenage morbidity and mortality. Giving birth at a younger age also increases the risk of infant mortality and childhood stunting and wasting. The female must meet her own nutritional needs for the growth that occurs during adolescence as well as foetal needs (Dasra, 2011). Iron, calcium, and folic acid (folate) is indicated. Low weight before pregnancy can increase risk for complications during pregnancy and poor outcomes for the child.

Conclusion

The health needs of formerly trafficked children and adolescents are diverse and significant. It is necessary to assess for undernutrition prior to or during their trafficking experience; to consider the particular nutrition demands of the child or adolescent; and to consider the other health outcomes that can also impact an individual’s nutrition status and needs. These include mental health conditions, mood and/or eating disorders, HIV/AIDS and pregnancy. More research is needed to determine specific nutrient requirements and support for individuals recovering from a trafficking experience.